White House Opioids Summit Highlights Plans to Fight Crisis

White House Opioids Summit Highlights Plans to Fight Crisis

Attendees at a White House Opioids Summit on Thursday — including President Donald J. Trump, cabinet members, and the surgeon general — detailed programs and voiced ideas to fight the opioid epidemic.

“It’s a problem that is growing,” Trump said. “People go into the hospital with a broken arm and they come out addicted, and they don’t even know what happened.”

His administration plans to roll out new policy over the next 3 weeks, and it will be “very, very strong,” Trump said.

He suggested the option of the death penalty for drug dealers, although that is not an item in any official policy.

“We have pushers and drugs dealers, they are killing hundreds and hundreds of people,” Trump said. “If you shoot one person, they give you life, they give you the death penalty. These people can kill two thousands, three thousand people and nothing happens to them.”

Legal action against the opioid manufacturers is another possibility. Trump acknowledged similar lawsuits filed by states and said he saw no reason the federal government could not do the same.

Regarding the multiple, ongoing challenges of the opioid epidemic, “We’re with you 100%, and we’re going to win,” he told summit attendees gathered in the East Room of the White House.

“Everyone in this room knows our country is in the middle of an opioid crisis,” said First Lady Melania Trump in opening the summit. She is proud of the work that has been done so far by the administration, she said, adding, “We all know there is still much work still to be done.”

Melania Trump was referring, in part, to the administration’s declaration of a public health emergency regarding the opioid epidemic in October 2017. Actions taken since the declaration include a doubling of annual funding for the Department of Health and Human Services (HHS) to promote opioid addiction prevention, treatment, and recovery. The proposal in Trump’s budget would increase funding from $500 million to $1 billion.

Department of Health and Human Services Response

“This year and last, we’re issuing $500 million in targeted response grants to state governments, which cover prevention and treatment but also recovery support,” HHS Secretary Alex Azar said during a panel discussion at the summit. “We are also working on a $150 million grant program for rural treatment,” he noted.

“We know we need to treat addiction as a medical challenge, not as a moral failing,” Azar said. “That informs HHS’s position across all three areas we’re here to discuss today: prevention, treatment, and recovery.”

Promising trends in opioid prescribing patterns are encouraging, Azar said, but he echoed the theme that more needs to be done. “Prescribing is down noticeably from 2010 to 2015, but it’s still three times what it was in 1999,” he said.

Azar emphasized the importance of evidence-based medication-assisted treatment of opioid addiction. However, only one third of US treatment facilities offer medication-assisted therapy. “That’s unacceptable — it’s an evidence-based approach.”

Two forthcoming guidelines from the US Food and Drug Administration will expand and accelerate medication-assisted treatment, Azar announced. “One will help the development of long-acting depo formulation, like the monthly shot approved this last fall. The other will open up new ways of assessing medication-assisted treatment effectiveness by looking at…alternative endpoints besides achieving complete abstinence.”

In terms of solutions, Azar said HHS has solicited states to request waivers to support substance abuse treatment. Since the public health emergency declaration, the department has approved waivers for five states. During the summit, Azar publicly invited more states to participate.

HHS organized an opioid “code-a-thon” in December that brought data science experts from Yale, Stanford, and Johns Hopkins universities and top technology companies. Use of data to identify troublesome trends in opioid abuse and to target resources was among the goals. “The programmers spent the day coming up with new tools for prevention — like apps that use existing datasets to monitor risky opioid prescribing and to help providers assess their own prescribing levels to see if they are out of the norm.”

Veterans Affairs Action

The US Department of Veterans Affairs (VA) took an unprecedented step about 2 months ago, said David Shulkin, MD, secretary of the VA. “We now publish, publically, all our opioid prescription rates for every VA medical center across the country,” he said.

The highest rate in the country is in Roseburg, Oregon, at 20% of all prescriptions; the lowest is in Cleveland, at 3%. “We’re the only health system in the country that does this,” Shulkin said. He hopes that VA’s approach will serve as a model for others.

“I have three points I want to share with you,” Shulkin continued. “The first is that I do believe, I’m optimistic, that we can make a difference.”

As the country’s largest health system, he said, the VA recognized the devastating effects of the opioid epidemic early. “We started focusing on this in 2011. In 2012, we launched the Opioid Safety Initiative that has put in more than $300 million toward prevention and treatment,” he said.

The initiative also aimed to promote appropriate prescribing. “Since 2012, we’ve reduced the number of opioids used in the VA by 41%,” he said. Part of the success, he explained, comes from a 90% reduction in new opioid prescriptions and from considering alternative methods of pain management.

His second point concerned the importance of sharing best practices from around the country in addressing the opioid epidemic. “We have a lot to learn from each other,” he said.

His third point concerned the principles that helped the VA realize a 41% drop in overall opioid prescribing. He presented the following STOP PAIN acronym:

Step care model to pain management — Opioids are not considered first-line therapy.

Treatment alternatives — “We’ve really focused on integrative medicine, nonmedicinal options, and the medication-assisted treatments.”

Ongoing monitoring and usage — Data are used to show bumps in high opioid usage rates.

Practice guidelines — The Department of Defense, the VA, and the CDC have published joint guidelines.

Prescription monitoring — “I am still a practicing internist, and I can go to the state database to see if other doctors have prescribed opioid medications,” Shulkin said.

Academic detailing — VA pharmacists train their doctors on how to appropriately prescribe opioids.

Informed consent — Patients have a shared responsibility in countering opioid abuse.

Naloxone distribution — The VA has distributed more than 100,000 naloxone kits to first responders and veterans. “We know that saves lives,” he said.

Housing and Urban Development’s Role

US Department of Housing and Urban Development (HUD) Secretary Ben Carson, MD, was also a member of the panel. “At HUD, the human cost of opioids is all too familiar. Drug addiction lands at the intersection of health, housing, and economic opportunity,” he said.

In fiscal year 2017, 67,000 persons, or approximately 25% of those served in the HUD’s Continuum of Care Program, reported having problems with substance abuse, Carson said. “That’s a lot of folks.

“It’s not just a crisis of health, it’s a crisis of hope,” he added.

During a question-and-answer session at the summit, an attendee who struggled with opioid addiction spoke of the difficulty in accessing treatment and recovery programs.

Carson said, “As a society we have to recognize that until it becomes as easy to get treatment as it is to get the drugs, we’re not going to win the battle.”

“No state has been spared, and no demographic group has been untouched,” said Kelleyanne Conway, counselor to the president and summit moderator. “For the courageous family members who have suffered loss and for those individuals currently suffering…we hear you and see you.”

Office of National Drug Control Policy

“This is one of the president’s greatest priorities,” said Jim Carroll, who started serving 1 week ago as acting director of the Office of National Drug Control Policy. “I’ve seen how this tears families apart,” he said.

Carroll made a personal revelation at the summit. He explained that Kathryn Helgaas Burgum, the First Lady of North Dakota, noted that 1 in 7 residents of her state know a family member, friend, or neighbor who is affected by the opioid epidemic.

“For the first time publicly, I want to tell you that I am that ‘1 in 7,’ ” Carroll said. He explained that opioid addiction affected one of his family members. “So it’s a great honor for me to take this on. This is a professional and personal challenge for me, for the president, and for every member of this administration.”

Another Personal Story Shared

As part of a video presentation of personal stories of people affected by the opioid epidemic, US Surgeon General Jerome M. Adams, MD, MPH, shared a personal story as well.

“I’m a physician. I have a master’s degree in public health, and I’m the US Surgeon General. My family is suffering from substance use disorder. My brother is in prison because of crimes he committed to support his addiction,” he said.

This has affected his entire family “emotionally, medically, and financially,” Adams said.

“As a trauma anesthesiologist, I have seen things that would make the average person cringe. But nothing has shaken me quite like seeing the barbed wire and the thick metal bars when I first visited my little brother in the state prison.

“I’m hopeful that by sharing my story, it will help people understand addiction touches every family, and they are not alone,” Adams said. “For me and for all too many Americans, stopping the opioid epidemic is not only pressing, it’s personal.”

For more Medscape Neurology news, join us on Facebook and Twitter.

Source link

MI Scar Often Seen in Women With Chest Pain, No Obstructive CAD

MI Scar Often Seen in Women With Chest Pain, No Obstructive CAD

The prevalence of myocardial scar by cardiac magnetic resonance (CMR) imaging was 8% in a prospective study of women presenting with angina-like chest pain but in whom prior clinically driven angiography had not shown obstructive coronary disease.

Such scar defined by late gadolinium enhancement at CMR is a sign of prior myocardial infarction (MI), yet a third of women with the sign had no prior MI diagnosis.

Moreover, about 1% of the cohort showed new scar at CMR a year later. That was only two patients in this series, but in neither case was an MI diagnosed during the follow-up, report investigators from the Women’s Ischemia Syndrome Evaluation–Coronary Vascular Dysfunction (WISE-CVD) study.

The findings add to abundant evidence that an MI diagnosis is missed in many women with suggestive symptoms but no obstructive CAD by angiography, observed Janet Wei, MD, Cedars-Sinai Heart Institute, Los Angeles, California, for theheart.org | Medscape Cardiology.

They also underscore the need for additional testing in such cases. “If a woman has persistent symptoms, especially if she’s had an actual myocardial infarction, just stopping at a ‘normal’ angiogram doesn’t actually give you any answers,” said Wei, who is lead author on the WISE-CVD analysis published February 19 in Circulation.

Previously in the primary WISE observational study, “We found that over half of these women who have symptoms of ischemia and no obstructive coronary disease do have coronary microvascular dysfunction.”

In addition, the symptom pattern of myocardial ischemia in women can be different from that in men, and not recognized as due to ischemia. In such cases, women may be told their pain is noncardiac or perhaps due to anxiety, Wei said.

“If they are felt to be low risk because they may have previously undergone testing that showed no obstructive coronary disease, they’re often told their heart is fine, so they may not actually receive optimal testing,” she said.

“It is a mind set that we need to overcome. This is a large proportion of the population, and these patients do unfortunately have worse outcomes, so we can’t just take no for an answer.”

CMR imaging with late-gadolinium enhancement disclosed myocardial scar in 26 of the 340 women with angina-like symptoms but negative angiograms, the report notes. 

Of those 26 women, 18 had a confirmed history of acute MI but only 2 had electrocardiographic Q waves consistent with prior MI.

Also, the 26 with scar shown by imaging showed functional signs of myocardial remodeling, with significantly lower LV ejection fraction and higher end-diastolic and end-systolic volumes.

There was no significant difference in myocardial perfusion reserve index (MPRI), a predictor of coronary microvascular dysfunction, between women with vs those without scar.

Table. Functional Parameters of CMR Imaging by Presence of Scar by Late Gadolinium Enhancement

Endpoints	No Scar (n = 314)	Scar (n = 26)	P Value
LVEF (%)	68	63	.004
LV end-diastolic volume (mL)	122	136	.01
LV end-systolic volume (mL)	39	51	.002
LV mass (g)	93	96	.42
MPRI	1.84	2.00	.12

 

Among 179 women in the series who were prospectively followed by CMR imaging at 1 year, 2 (about 1.1%) showed a presence of new scar in myocardium that had not previously shown late gadolinium enhancement.

Both of those two women with new scar, Wei said, had been hospitalized for angina during the year-long follow-up, but neither was diagnosed with MI.

Wei reports no conflicts of interest. Disclosures for the other authors are in the report.

Circulation. Published online February 19, 2018. Abstract

Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

Source link

Bystander Defibrillation May Double Cardiac Arrest Survival

Bystander Defibrillation May Double Cardiac Arrest Survival

People who had a cardiac arrest in a public place and received an automated external defibrillator (AED) shock by a bystander were more likely to make a full neurologic recovery compared with those receiving defibrillation by a first responder, in a new study.

Specifically, 57% of people with a shockable cardiac arrest who received a bystander-delivered AED shock survived and were discharged from the hospital with no neurologic disability compared with 33% of people who received defibrillation from an emergency medical service (EMS) responder, a statistically significant difference.  

These findings from the US and Canadian Resuscitation Outcomes Consortium (ROC), by Ross A Pollack, BS, Johns Hopkins University School of Medicine, Baltimore, and colleagues were published February 26 in Circulation.

Almost 20% of the people received a bystander-delivered AED shock, which is “a pretty good number,” senior author, Myron Weisfeldt, MD, Johns Hopkins University School of Medicine, told theheart.org | Medscape Cardiology.

Even when EMS responders can arrive within about 5.3 minutes, as in this study, “if a bystander can find a defibrillator, put it on and use it, they can double the chance of survival,” he noted.

“This study shows you really can save useful lives by having publicly available defibrillators, and obviously you need to train bystanders and encourage bystanders to use them. “

“The bottom line is this study provides additional strong evidence of the importance of public use of AEDs,” Circulation guest editor for this article, Christopher B Granger, MD, Duke University Medical Center, Durham, North Carolina, told theheart.org | Medscape Cardiology.

The next step is to increase the use of AEDs throughout the United States, he said. “In Denmark, for example, they’ve doubled or tripled the used of AEDs by the public in cardiac arrest, so we have good demonstration that it can be done.”

Bystander AED use is better in some parts of the United States than in other areas, so “we need to focus on this as a public health opportunity,” Granger said.

Time to Defibrillation Is Critical  

A person with shockable cardiac arrest, ventricular tachycardia and ventricular fibrillation, has much better survival odds than someone with cardiac arrest without a shockable rhythm, Pollack and colleagues note.

Three recent studies suggested that bystander AED use before the arrival of a first responder could improve the odds of surviving a shockable cardiac arrest, with excellent neurologic functional status.

The researchers aimed to compare functional outcomes after bystander AED use vs EMS shock in people with shockable out-of-hospital cardiac arrest in the nine ROC mid-sized cities (Seattle/King County, Washington; Dallas/Fort Worth, Texas; Pittsburgh, Pennsylvania; Milwaukee, Wisconsin; Birmingham, Alabama; Portland, Oregon; Toronto, Ontario; Ottawa, Ontario; and Vancouver, British Columbia), from 2011 to 2015.

Of 49,555 cardiac arrests that were treated by EMS personnel, 4115 (8.3%) occurred in a public setting and were witnessed by bystanders.

Of these, 2589 (63%) cardiac arrests had a shockable rhythm; 89 cardiac arrest cases were excluded from the current analysis because of missing data, “do not resuscitate” instructions, death on arrival at hospital, or not receiving an EMS-delivered shock.

Of the remaining people with shockable cardiac arrest, 469 (19%) received a bystander-delivered AED shock and 2031 people did not.

After adjustment for multiple variables, people with cardiac arrest who received a bystander AED shock vs those who received an initial shock from EMS personnel had 2.7-fold higher odds of surviving until they were discharged from the hospital with excellent neurologic function (modified Rankin Scale score ≤ 2; P < .001).

The odds of surviving to hospital discharge with excellent neurologic function with bystander defibrillation as opposed to EMS defibrillation were 1.86-fold higher if the EMS responder arrived within 4 minutes and 6.54-fold higher if the EMS responder arrived within 12 minutes.

“The longer it takes the EMS [responders] to get there, the more valuable the bystander defibrillation,” Weisfeldt noted.

Moreover, these were medium-sized cities. Larger cities with more traffic congestion, or cases of cardiac arrest occurring on the 100th floor of an office tower, necessitating a long elevator ride, would make bystander AED use even more critical.

Place AEDs Near Fire Extinguishers

To improve survival after public cardiac arrests, Granger said, we will need “more deliberate placement of AEDs in the public places where cardiac arrests are more likely to occur and training the public to use AEDs and integrating AED location information with the dispatch center.”  

When 911 responders know where the nearest defibrillator is, they can “direct bystanders to the nearest AED and get it used.”

“AEDs are designed to be easy to use and it should be self-explanatory,” he added, “but all too often in the United States, if you look at an AED on the wall, even at Duke Hospital, for example, half the time on the AED it says Only to be used by trained personnel,’ which is totally false.”

“The data advocates strongly for the idea of a uniform presence of a defibrillator in large public buildings in a uniform place,” Weisfeldt said. “We do better than [this] for fire, which is far less of a threat.”

A statement issued by the American Heart Association (AHA) notes that in a witnessed, out-of-hospital cardiac arrest, the first step is to call 911 and immediately start cardiopulmonary resuscitation (CPR), and then follow the directions on the AED.

For every minute without CPR, the chance of death increases by 10%.

One of the study’s limitations is that it only examined bystander AED use without considering the combined impact of calling 911 and starting immediate CPR.

A 2017 AHA survey found that most US employees lack training in CPR and first aid, and half could not locate the AED at their workplace.

“First aid, CPR, and AED training need to become part of a larger culture of safety within workplaces,” said Michael Kurz, MD, chair of AHA’s Systems of Care Subcommittee and associate professor at the University of Alabama School of Medicine in the Department of Emergency Medicine.

“We are certainly seeing higher public interest in this training, and our campaign calls upon decision makers in workplaces and popular public spaces, such as arenas, fitness centers, hotels, and churches, to place AEDs in the same locations as a fire extinguisher.”

ROC is funded by the National Heart, Lung, and Blood Institute in partnership with the National Institute of Neurological Disorders and Stroke; US Army Medical Research & Material Command; the Canadian Institutes of Health Research (CIHR)– Institute of Circulatory and Respiratory Health, Defense Research and Development Canada; the Heart, Stroke Foundation of Canada; and the American Heart Association. Pollack and Weisfeldt have no relevant financial disclosures, and the financial disclosures of the other authors are listed with the article.

Circulation. Published online February 26, 2018. Abstract

For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook .

Source link

Light Exercise 'Helps Older Men Live Longer'

Light Exercise 'Helps Older Men Live Longer'

When it comes to getting enough exercise, older men should concentrate on sitting less and moving more to lower their risk of dying prematurely, researchers say.

A study in the British Journal of Sports Medicine says men in their 40s and 50s accumulate some health benefits from light intensity exercise, even if they don’t have the time or inclination to get the full 150 minutes a week of moderate intensity activity that guidelines recommend.

The research team, led by University College London, say their findings could help make the guidelines more achievable for older adults.

Getting Enough Exercise

These guidelines currently say that adults aged up to 64 should:

· Take part in moderate intensity activities for at least 150 minutes (2½ hours) a week in bouts of 10 minutes or more

· Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week, or combinations of moderate and vigorous intensity activity

· Take part in muscle strengthening exercises on at least 2 days a week

· Minimise the amount of time spent being sitting for extended periods

The researchers say this pattern of exercise is particularly difficult for older men to achieve and they set out to assess how people in this age group could use exercise to stay healthy.

Health Study

They looked at data from 7,735 men recruited from 24 GP practices in the late 1970s when they were aged between 40 and 59.

The 3,137 men who were still alive in 2010-12 were invited for a health check-up, which included a physical examination, and asked about their lifestyle, sleeping patterns, and whether they had ever been diagnosed with heart disease.

Around half the men agreed to wear an accelerometer to track their activity levels during waking hours for a week and data was available for 1,181 of the men who had no pre-existing cardiovascular disease at the outset and who were by then aged 78 on average.

The researchers report that any amount of physical activity, including light exercise, was linked to a lower risk of dying.

Also, each extra 30 minutes a day of light intensity activity, such as gentle gardening or taking the dog for a walk, was associated with a 17% reduction in the risk of dying.

The researchers say that although these men might have doubled their protection against dying if they had upped their exercise from light to moderate, the benefits of light exercise should not be discounted.

They also found that following official advice to have bouts of exercise spread across the week of 10 minutes or more did not change the risk of dying in men in this age group.

‘It’s Never Too Late to Get Active’

In an emailed comment, Emily McGrath, senior cardiac nurse at the British Heart Foundation, says: “Moderate intensity exercise, at any age, can improve your heart health as well as lowering your blood pressure, cholesterol and helping you lose excess weight.

“Research shows just 20 to 30 minutes of exercise per day can make a difference – anything that increases your heart rate and makes you breathe a little faster will improve your health.

“It’s never too late to get active and even a little physical activity is better than none.”

SOURCES:

Objectively measured physical activity, sedentary behaviour and all-cause mortality in older men: does volume of activity matter more than pattern of accumulation?, Jefferis B, British Journal of Sports Medicine

Livewell, NHS

British Heart Foundation

Source link

Clinicians and Medical Students Hesitant to Hug Patients

Clinicians and Medical Students Hesitant to Hug Patients

When asked in a Medscape Medical News poll whether they hugged their patients, physicians, nurses, and medical students were selective to different degrees.

Nurses and advanced practice nurses (APRNs) who responded to the poll, posted January 24, were more likely to frequently hug their patients than physicians were (19% vs 13%, respectively). Only 5% of medical students said they frequently hug their patients.

Medical students were much more likely to bypass the situation, with 41% answering that they never hug patients. About half that number of physicians (21%) and only 6% of nurses drew the line at “never.” For most in all categories, the predominant answer was “sometimes.”

Sex and age helped predict frequency of hugs among physicians, according to the poll. More female physicians than male said they frequently hugged patients (15% vs 11%) and sometimes hugged them (72% vs 61%).

Under-35-year-old physicians and those 35 and older had the same percentage for sometimes hugging patients (66%), but the differences came in the extremes. Only 5% of physicians younger than 35 frequently hugged patients compared with 15% of those older than 35, and 29% of the younger physicians said they never hug patients compared with 19% of the over-35 physicians.

A total of 3072 readers responded to the poll: 1579 nurses/APRNs, 1432 physicians, and 61 medical students.

Longtime Patients Most Likely to Get Hugs

The patients most likely to get hugs from clinicians were longtime patients. Thirty-seven percent of nurses said longtime patients were the patients they would most likely hug, and 34% of physicians agreed.

Next were older patients and patients receiving bad news. In these two categories, generally 16% to 18% of respondents said they were groups most likely to get hugs.  Medical students were an exception, as only 3% agreed that they were most likely to hug those getting bad news

According to the poll numbers, children were among the least likely to get hugs from their care provider. Only 8% of nurses, 6% of physicians, and 5% of students said that group was most likely to get hugs.

A home health nurse commented that no demographics matter when it comes to hugs: Everybody needs them.

She wrote: “I have discovered many times, the only time patients are touched is when someone is doing something to them. That is not therapeutic, nurturing touch that we all need. So, I tell all of my patients at the end of my visit that I have a rule, and that rule is I need to give them a hug. They absolutely light up!”

Few Negative Reactions to Hugs

Like the home health nurse, others who like to hug may take comfort in the low numbers of clinicians who have experienced negative reactions to hugs. Only 4% of nurses, 3% of physicians, and 2% of medical students said they have experienced negative reactions.

Some providers pointed out in the comments section that hugging patients may depend on how clinicians feel about hugging people in general.

One family medicine physician answered that she hugs only her spouse, kids, and grandkids. “I did not grow up with the ‘hello/goodbye’ hug, and not really comfortable with people who do that to me,” she wrote.

Some commenters wrote that they let patients initiate the hug. Others offered more direct caution. A psychologist wrote, “It isn’t really safe, from a legal standpoint, to hug patients.” A nurse cautioned, “You have to be very careful that this is not looked at with sexual overtones.”

Art Caplan, PhD, a medical ethicist at New York University School of Medicine and a Medscape columnist, writes that in light of the #MeToo movement, healthcare providers may be understandably nervous about touching a patient.  But he says a hands-off, no-compliments attitude goes too far.

He writes, “People will understand what is going on when you are doing something in front of others in a hospital setting. I am not saying that we should be dishing out hugs in the office with the door closed. That is clearly not appropriate. When you are in situations in which you are trying to use contact and physical interaction as a way to show concern and empathy, that should be preserved.”

Hugs Can Have Lasting Meaning

Some commented that hugs can have immense and lasting meaning.

A nurse who works with HIV-infected patients wrote that “one guy I hugged started crying because no one had touched him in 6 years.”  Another wrote, “When my father passed away his physician hugged my Mum and 5 years later she still talks about this.”

When asked whether specialty might make a difference in whether hugs would be acceptable, 46% of nurses said yes, and 48% of physicians and 62% of medical students agreed.

For those hesitant to hug, there may be a good alternative. One commenter from psychiatry/mental health wrote: “A warm and respectful hand over the shoulder is really good. It is really appreciated by older people.”

For more news, join us on Facebook and Twitter

Source link

Legalized Marijuana: Fewer Risks, Fewer Benefits

Legalized Marijuana: Fewer Risks, Fewer Benefits

Legalization of medical marijuana has both fewer risks and fewer benefits than previously reported, new research shows.

A meta-analysis of 11 studies conducted between 1991 and 2014 shows there is no evidence to support the hypothesis that US medical marijuana laws (MMLs) have led to an increase in the prevalence of marijuana use among adolescents.

“For several years, people have been very concerned about the potential for medical marijuana laws to lead to increases in teen use of marijuana, because early heavy use is associated with impaired neurodevelopment, educational, and occupational achievement,” senior author Deborah Hasin, PhD, professor of epidemiology in psychiatry, Columbia University, New York City, told Medscape Medical News.

“The results were quite clear — MML did not lead to increases in teen marijuana use,” she said.

In an accompanying editorial, investigators concluded that it is “premature” to believe that increased access to medical marijuana may help solve the US opioid crisis.

“The purpose of our editorial was to point out how weak such correlational evidence is in supporting the claim that medical cannabis has reduced opioid overdose deaths,” lead author Wayne Hall, PhD, professor, Center for Youth Substance Abuse Research, University of Queensland, Australia, told Medscape Medical News.

He cautioned US state legislative bodies against “drawing the policy conclusion that they could reduce opioid overdose deaths by either allowing medical use of cannabis or by expanding access to medical cannabis.”

The study was published online February 22 in Addiction.

Unanswered Questions

As of November 2016, 28 states had enacted policies legalizing marijuana use for medical purposes, but “public debate has focused on the potential for MMLs to increase recreational use of marijuana in adolescents,” Hasin and coauthors write.

Hasin’s group previously conducted a study of the effects of MMLs in more than 1 million US teens, who were surveyed from 1991 to 2014. The investigators and found that MMLs did not increase teen marijuana use.

Nevertheless, “questions about MML effects remained, and we wanted a more definitive answer, so we did a thorough literature search, found 11 other studies that also examined nationally representative samples of US teens, and conducted a meta-analysis of the results from these studies,” she reported.

All studies were derived from four ongoing large national surveys: Monitoring the Future (MTF) (n = 2); the National Longitudinal Survey of Youth (NLSY) (n = 2); the National Survey on Drug Use and Health (NSDUH) (n = 4); and the Youth Risk Behavior Survey (YRBS) (n = 3).

Four studies excluded years prior to 2002; thus, these studies excluded data collected prior to the earliest passing of MMLs, in California, Oregon, Washington, and Colorado. In addition, two YRBS studies did not include these states.

All the studies used a difference-in-difference (DID) approach in estimating the effect of the passage of MMLs. In that approach, differences in marijuana use from pre- to post-MML passage were compared to contemporaneous differences in non-MML states.

Estimates were standardized and were entered into a meta-analysis model with fixed effects for each study.

None of the studies found significant changes in the estimates of the prevalence of use among adolescents before and after passage of MMLs, as compared with contemporaneous changes in non-MML states (P < .05). The studies did show, however, a nonsignificant pooled estimate (standardized mean difference) of -0.003 (95% confidence interval [CI] = −.012 to +.007).

The particular surveys (ie, MTF, NLSY, NSDUH, or YRBS) were not found to significantly affect study effect size (P = .46).

Four studies compared MML states with non-MML states with regard to differences in the prevalance of past-month marijuana use before the passage of MMLs. All four studies found that rates of past-month marijuana use were higher.

Caution Required

Although the study “shows a lack of medical marijuana laws’ effect on teens’ use,” the findings “do not tell us about what the effects of recreational marijuana laws will be,” she warned.

The findings also “do not diminish the importance of addressing early, heavy use of marijuana in teens, wherever it occurs.”

Additionally, “the few studies available suggest that medical marijuana laws do increase cannabis use and adverse cannabis outcomes in adults,” she said.

Commenting on the study for Medscape Medical News, Stephanie Hartselle, MD, clinical assistant professor of psychiatry, Brown University, Providence, Rhode Island, who was not involved with the study, expressed “serious” concerns regarding its conclusions.

The exclusion from some of the studies of four states in which medical marijuana use has been legal longest “may have slanted the study in a dramatic way, but it’s difficult to assess, given how long these laws have been in place,” she said.

In addition, ” ‘past-month use’ is a very short parameter to use, given the time it takes for laws to be passed and for approval of medical marijuana authorizing clinics and venues for purchase to be established,” she observed.

She noted that “many physicians involved in authorizing the use of medical marijuana in most states will do so for adults only and not for those under the age of 18,” so “finding a prescriber to approve a diagnosis qualifying for a medical marijuana card may have been difficult, if not impossible, in these states.”

For that reason, “evaluating teen use in this context over 1 month may be a narrative to the system of health rather than elucidating the effect of these laws on teen cannabis use.”

Also commenting on the study for Medscape Medical News, Austin Miller, MPP, a PhD candidate at Washington State University, in Pullman, who was not involved in the study, noted, “The interplay between MML and marijuana use is complex” and “not all medical marijuana use is the same.

“Different provisions within such laws are likely to have different effects on adolescent marijuana use, so the respective effects of such different provisions are nonconclusive with the current evidence,” he added.

Hasin said that her group plans to conduct “continued monitoring of MML and recreational marijuana laws in teens and more studies in adults.”

No Impact on Opioid Use

The editorial by Hall and colleagues challenges the claim that an increase in access to medical cannabis will reduce opioid overdose deaths, calling the evidence “very weak.”

They challenge a previous “ecological study” that showed a correlation over time between the passage of MMLs and decreasing opioid overdose death rates.

Ecological studies “do not show directly that it is increased medical cannabis use in these states that has reduced opioid use in individuals,” the authors state.

Furthermore, these studies “have limited capacity to control for the effects of important differences” between those states with and those without MMLs. Such differences include increased access to methadone- and buprenorphine-assisted treatments for opioid dependence, which might reduce overdose risks, the authors point out.

Although the low risk for overdose from cannabinoids is “well established,” their analgesic efficacy is “modest,” and epidemiologic studies of large samples of patients with chronic pain “have found that those who use cannabis do not use lower opioid doses than opioid users who do not use cannabis.”

Hall emphasized that there “are much better treatments that have been shown to reduce overdose deaths that are not currently being widely used in the states.” These include medication-assisted treatments with methadone or buprenorphine.

Commenting on the editorial for Medscape Medical News, Mark Olfson, MD, MPH, professor of psychiatry and epidemiology, Columbia University, New York City, who was not involved in writing the editorial, agreed that, “on the basis of current evidence, it is premature to expand access to medical cannabis as a general strategy to curtail the opioid crisis.”

However, “at the same time, there may be a narrow clinical role for medical cannabis to help with acute pain management in some opioid-dependent patients,” he said.

He noted that “prospective research is needed with opioid-dependent pain patients to help identify the clinical context in which medical cannabis provides analgesia and ameliorates opioid craving and consumption.”

Hall added that it “would be better to offer medication-assisted treatment to opioid-dependent people than to imprison them, because overdose deaths increase dramatically after opioid-dependent people are released from prison.”

The meta-analysis was supported by the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the New York State Psychiatric Institute. The authors and editorialists have disclosed no relevant financial relationships.

Addiction. Published online February 12, 2018. Full text, Editorial

Source link

Never Too Late? Surgery Near End of Life Is Common, Costly

Never Too Late? Surgery Near End of Life Is Common, Costly

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Redberg, who at the University of California-San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a 2011 study in The Lancet.

More than 12 percent of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Dr. Eleni Linos has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When Less Is More

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors — ever.”

According to the University of Michigan’s National Poll on Healthy Aging, published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those who’d been told they needed an X-ray or other test — but weren’t sure they needed it — went on to have the procedure anyway.

Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.

Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in three to five years. I doubt I’ll be here.”

Finding Solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.

Schwarze said, “If someone says they can’t tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test —not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.

Source link